Customer Support / Forms

Independence Blue Cross Forms

• Enrollment/Change Form
• Claim Reimbursement Forms
• Point of Service Claim Form
• Personal Choice Out-of-Network Claim Form - Individual
• Personal Choice Out-of-Network Claim Form - Group
• Influenza Vaccine Reimbursement Form
• Application to Continue Coverage for Handicapped Dependent Child
• FutureScripts Prescription Drug Reimbursement Form
• Prescription Mail Service Order Form
• Prescription Drug Medication Request Form
• Authorization to Release Form
• Personal Representative Form
• Guest Membership Application
• IBC / Keystone Medicare Forms 
• Personal Choice 65 Disenrollment Form
• Keystone 65 Disenrollment Form
• Select Option Disenrollment Form

United Concordia Forms

• United Concordia Enrollment Form
• United Concordia Claim Form

 

COBRA Model Notices - for Self Administered Groups  

• COBRA Model Notice FAQs: https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/cobra-model-notices.pdf
   
• COBRA Model General Notice: https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-general-notice.docx
    
• COBRA Model Election Notice: https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-election-notice.docx

• COBRA Model General Notice (Spanish): https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-general-notice-spanish.docx

• COBRA Model Election Notice (Spanish): https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/cobra/model-election-notice-spanish.docx